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~~~~~~~~~~~ 香港通」旅遊保險 - 至尊計劃申請表格 ~~~~~~~~~~~
此保險由「藍十字(亞太)保險有限公司」承保

請列印這張申請表格,並填上有關資料後傳真回 852-25197296 綜匯旅遊有限公司。

Agent Code: 95903303

Applicant 申請人 Please complete this from in English BLOCK Letters. (此表格必須以英文正楷填寫)
* Fields must be filled in. (此欄必須填寫)
Name of Applicant 申請人姓名*              
(Mr/Ms/Mrs)          Surname                             Given name
Company Name 公司名稱 Phone # 聯絡電話*
E-mail Address 電子郵箱 * Fax # 傳真號碼
Commencement Date 起保日期 *  (DD/MM/YYYY) For Days
(/月/年)                                         共                                       日
Correspondence Address 通訊地址*


Premium Type Selected 保險類別 * Insured 被保人   Family 家庭
Details of Insured Persons 被保人資料
Mr/Ms/Mrs Surname * Given Name * Age 年齡 * Passport No.旅遊證件號碼 * Premium 保費 *HK$
1.
2.
3.
4.
5.
Total premium for this insurance 總保費: HK$
Declaration 聲明
The applicant warrants that to the best of his/her knowledge and belief no insured person is travelling contrary to the advice of a medical practitioner or for the purpose of obtaining medical treatment and that he/she understands that treatment of any pre-existing, existing, recurring or congenital medical conditions is not insured.
申請人保證並據實相信各被保人絕不會違反醫生的囑咐或僅為獲得醫療而外出旅遊。各被保人更清楚明白任何現已存在之疾病、現有、不時復發或先天疾病皆不在承保之列。

Personal Information Collection Statement 收集個人資料聲明
I/We understand and agree that any personal information collected or held by Blue Cross (Asia-Pacific) Insurance Limited ("the Company") may be used, stored, disclosed and transferred (within or outside of Hong Kong) to such individuals/organizations associated with the Company or any selected third party for the purposes of processing this application and providing subsequent services for this, and promotion of financial products or services by the Company and its affiliated companies, and communicating with me/us for such purpose. I/We the right to obtain access to and to request correction of any personal information held by the Company. Such request could be made to Company's Corporate Data Protection Officer at 29/F, BEA Tower, Millennium City 5, 418 Kwun Tong Road, Kwun Tong, Kowloon, Hong Kong .
本人/ 我們明白並同意貴公司可使用及保存所收集或持有本人 /我們之個人資料,並可將此等資料使用、儲存、透露及轉達 (於本地或以外 ) 予任何與貴公司有關之人士 /機構或被選定之第三者,用以處理及審核此項申請及提供有關之服務,介紹貴公司及其聯營公司之財務產品或服務,及與本人 /我們聯絡。本人/我們有權致函 香港九龍觀塘道418號創紀之城五期東亞銀行中心29樓 向貴公司之個人資料保護主任查詢及要求更正貴公司所持有之個人資料。

 




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Applicant's Signature 申請人簽名

Date (DD/MM/YY) 日期 (//)


The chinese copy of this application form is for reference only. Should there be any queries or disputes, please refer to the English version.
本投保書之中文譯本只供參考之用,如有爭議,應以英文版本為準。

All insurance transactions must be arranged within the territory of the Hong Kong Special Administrative Region.
所有的保險項目必須在香港安排
Tiglion Travel Services Company Limited (Lic 350005) and (Insurance Agent Reg 95903303)
[ Insurance Agent for Blue Cross (Asia-Pacific) Insurance Limited ]

Disclaimer
Rm 902 Yue Xiu Building, 160-174 Lockhart Road, Wanchai, Hong Kong
Tel 852-25117189   Fax 852-25197296

Email: travel@tiglion.com Website: http://www.travel.com.hk 
Copyright (c) 1995 - Tiglion Consultancy Company Limited. All rights reserved.